Provider Demographics
NPI:1336129816
Name:JOHNSON, SHIRLEY K (CPNP, PNP)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:K
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CPNP, PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-467-5384
Mailing Address - Fax:
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-467-5384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR143918-8208000000X, 363L00000X
IAC077838363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN322100800Medicaid
MN500008374OtherRAILROAD MEDICARE
IAENROLLEDMedicaid
WIENROLLEDMedicaid
MN500004775Medicare PIN
MN500001006Medicare PIN
IAENROLLEDMedicaid
MN322100800Medicaid